Psychological impact of the COVID-19 epidemic among healthcare workers in paediatric intensive care units in China

To perform a mental health evaluation and an early psychological intervention for healthcare workers (HCWs) during the coronavirus disease 2019 (COVID-19) epidemic, an online survey was conducted among 3055 HCWs in the paediatric intensive care units (PICUs) of 62 hospitals in China on March 26, 2020, by the Neurology and Sedation Professional Group, Emergency Department, Paediatrics Branch, Chinese Medical Association. The questionnaire was divided into three parts, including general information, the Impact of Event Scale-Revised (IES-R), and the Depression Anxiety Stress Scale-21 (DASS-21). The results show that a total of 970 HCWs (45.99%) were considered to meet the clinical cut-off scores for posttraumatic stress (PTS), and the proportions of participants with mild to extremely severe symptoms of depression, anxiety and stress were 39.69%, 36.46% and 17.12%, respectively. There was no significant difference in the psychological impact among HCWs of different genders. Married HCWs were 1.48 times more likely to have PTS than unmarried HCWs (95% Cl: 1.20–1.82, p <0.001). Compared with junior professional title participants, the PTS-positive rate of HCWs with intermediate professional titles was 1.91 times higher (90% Cl: 1.35–2.70, p<0.01). Those who had been in contact with confirmed COVID-19 cases were 1.40 times (95% Cl: 1.02–1.92, p <0.05) more likely to have PTS than those who did not have contact with COVID-19 cases or did not know the relevant conditions. For depression, the proportion of HCWs with intermediate professional titles was significantly higher, at 1.65 times (90% Cl: 1.17–2.33, p <0.01) that of those with junior professional titles. The depression of HCWs at work during the epidemic was 1.56 times that of HCWs on vacation (95% Cl: 1.03–2.37, p <0.05), and their anxiety was 1.70 times greater (95% Cl: 1.10–2.63, p <0.05). Participants who had been in contact with confirmed COVID-19 cases had more pronounced anxiety, 1.40 times that of those who did not have contact with COVID-19 cases or did not know the relevant conditions (95% Cl: 1.02–1.92, p <0.05). There was no significant correlation between the variables and the positive results of stress symptoms. In total, 45.99%, 39.69%, 36.46% and 17.12% of PICU HCWs were affected by PTS, depression, anxiety and stress, respectively, to varying degree. Married status, intermediate professional titles and exposure history were independent risk factors for PTS. Intermediate professional titles and going to work during the epidemic were independent risk factors for depression, and going to work and exposure history during the epidemic were independent risk factors for anxiety. In the face of public health emergencies, HCWs not only specialize in paediatric intensive care but also, as a high-risk group, must actively take preventive measures and use mitigation strategies.

Introduction psychological effects of PICU HCWs is very limited, and there are not enough sample data to report the psychological effects of the outbreak of COVID-19. To study the psychological impact of the COVID-19 outbreak on HCWs and analyse their independent risk factors, the Emergency Department of the Paediatrics Branch of the Chinese Medical Association investigated the mental health status of HCWs in PICUs across the country immediately after the COVID-19 epidemic was basically controlled in China to provide a reference for countries to conduct psychological interventions for HCWs as early as possible.

Materials and methods
This study is a multicentre, cross-sectional online survey. Expedited ethics approval was obtained from the Institutional Review Board, Children's Hospital of Chongqing Medical University (CHCQMU-IRB-2020-304), which conformed to the principles embodied in the Declaration of Helsinki. The online questionnaire was sent to 62 hospitals in 31 provinces (municipalities or autonomous regions) of China on March 26, 2020. The questionnaires were distributed to a total of 3055 HCWs in these 62 hospitals, and a total of 2116 questionnaires were collected on April 15, 2020. Seven questionnaires were excluded due to improper completion, leaving a total of 2109 questionnaires. Since the questionnaire was completed voluntarily, the response rate was not calculated. All participants voluntarily responded to the survey anonymously and provided informed consent online before the survey.
In this study, statistical analysis was performed using SPSS Statistic 25.0 (IBM SPSS Statistics, New York, United States). The count data are expressed as percentages, and the measurement data are expressed as averages and standard deviations. T-tests, F-tests, chi-square tests, and binary logistic regression were used to analyse the data. Statistical significance of all the two-tailed tests was set at p < 0.05.

Results
A total of 2109 HCWs completed the survey, of whom 85.02% (1793/2109) were female and 14.98% (316/2109) were male. Participants ranged in age from 20 to 60 years old, with an average age of 32.42 (SD = 6.66). A total of 739 HCWs (35.04%) were doctors, and 1370 HCWs (64.96%) were nurses. During the epidemic, more than 90% (1992/2109) of HCWs were still at work, of whom 20.8% (416/1992) remained on the front lines; 216 participants went to Wuhan or designated hospitals, and 200 participants went to isolation wards or fever clinics. The remaining baseline information is shown in Table 1.
The questionnaire contains two psychological scales: the IES-R, which is used to reflect the symptoms of PTS, and the DASS-21, whose three subscales are used to evaluate depression, anxiety and stress. A total of 970(45.99%), 837(39.69%), 769(36.46%) and 361(17.12%) participants had varying degrees of PTS and felt depression, anxiety, and stress, respectively. The severity of these conditions is shown in S1 Table. Comparing the baseline data between groups, as shown in Fig 1 and S2 Table, there were no significant differences in psychological distress among HCWs of different genders or educational backgrounds. HCWs who were married or had interacted with suspected COVID-19 cases in the isolation ward had more PTS. In addition to having more PTS, participants who lived in Wuhan or had been exposed to COVID-19 also showed more anxiety. Doctors had more depression and stress symptoms than nurses. During the epidemic, there was no significant difference in the stress of HCWs at work compared with those on vacation, but those at work scored higher on the rest of the scale. In the IES-R and DASS-21 depression subscales, the scores of 30-to 49-year-old HCWs were higher than those of younger HCWs, while the scores of HCWs with intermediate professional titles were significantly higher than those of HCWs with junior professional titles. HCWs with confirmed COVID-19 cases in their hospital or PICU scored higher on each scale, while those working in the PICU for less than 1 year scored significantly lower than those working in the PICU for more than 10 years. Fig 2 reveals that some variables are statistically associated with HCWs' PTS. Married HCWs were 1.48 times more likely to have PTS than unmarried HCWs (95% Cl: 1.20-1.82, p <0.001). Compared with participants with junior professional titles, the PTS-positive rate of HCWs with intermediate professional titles was 1.91 times greater (90% Cl: 1.35-2.70, p<0.01). Those who had been in contact with confirmed COVID-19 cases were 1.40 times (95% Cl: 1.02-1.92, p <0.05) more likely to have PTS than those who did not have contact with COVID-19 cases or did not know the relevant conditions. As shown in Fig 3, for depression, the proportion of HCWs with intermediate professional titles was significantly higher, at 1.65 times (90% Cl: 1.17-2.33, p <0.01) that of those with junior professional titles. The depression level of HCWs at work during the epidemic was 1.56 times that of HCWs on vacation (95% Cl: 1.03-2.37, p <0.05), and their anxiety was 1.70 times greater (95% Cl: 1.10-2.63, p <0.05) (Fig 4). Participants who had been in contact with confirmed cases had more pronounced anxiety, 1.40 times that of those who did not have contact with COVID-19 cases or did not know the relevant conditions (95% Cl: 1.02-1.92, p <0.05) (Fig 4). As shown in S3 Fig, the multivariate logistic regression analysis shows that there is no significant correlation between the variables and the positive stress symptoms results.

Discussion
Among the HCWs participating in the survey, women accounted for 85.02% (1793/2109) and men accounted for 14.98% (316/2109), basically in line with the ratio of males to females in the 2019 Chinese Health Statistics Yearbook [38]. Therefore, this survey can roughly reflect the psychological distress of PICU HCWs.
In this epidemic, 45.99%, 39.69%, 36.46%, and 17.12% of PICU HCWs had varying degrees of PTS, depression, anxiety, and stress, which were much lower than those of the Brazilian general population in the same study earlier in the epidemic (54.9%, 61.3%, 44.2%, and 50.8%) [30]. At the same time, the report also shows that 84.4% of the research population felt insecure. Given the public's lack of professional knowledge, they were easily confused and driven to fear by a large amount of false information on the Internet; therefore, their psychological status was more vulnerable to the impact of the epidemic. The prevalence of depression, anxiety and stress among participants was higher than that among Chinese HCWs in the same study [33]. To a certain extent [39], this shows that PICU HCWs have a higher degree of psychological influence among all HCWs, and they have more depression, anxiety and stress.
Surprisingly, our research shows that there is no significant difference in the psychological impact among HCWs of different genders, which is inconsistent with many studies [40][41][42][43][44][45][46][47]. In the past, many psychology-related studies have shown that in different groups, not limited to HCWs, women's psychological endurance is weaker than that of men, and their psychological distress is greater [48][49][50]. This is probably due to our choice of research objects. The participants usually come into contact with patients with life-threatening illnesses, and they are always in a working environment where rescue procedures could be initiated at any time. They are always ready to fight the death, and thus their psychological health may be better than that of those in other departments.
Logistic regression showed that marital status was an independent risk factor for PTS. The COVID-19 epidemic broke out during the Chinese New Year [4]. As a traditional Chinese holiday for family reunions, married HCWs inevitably worried about infecting their families. However, based on the traditional concept of "marrying and giving birth children" in Chinese families, the greater difference between married and unmarried HCWs is the presence of children. As parents, they inevitably have more concerns because at that time, there were very few reports about children with COVID-19, and the diagnosis and treatment of children with COVID-19 had not been unified.
Many studies have shown that professional titles are related to psychological effects [42,51,52]. Our research also found that compared with those with junior professional titles, having

PLOS ONE
Psychological impact of the 2019 Coronavirus Disease (COVID-19) epidemic an intermediate professional title was an independent risk factor for PTS and depression. This may be due to an imbalance between the work experience of on one's title and the risk of exposure to cases, the burden and the ability to deal with emotions.
Still working during the epidemic was an independent risk factor for depression and anxiety. On the one hand, HCWs knew very little about the new virus, and they were constantly exploring and learning in the face of cases. This unpredictability greatly increased the workload. On the other hand, HCWs were at a higher risk of exposure to COVID-19 cases. They were more afraid of being infected and infecting others [17,19,20]. At the same time, successive reports of HCWs infections struck fear in them. These factors further exacerbated PICU HCW's depression and anxiety.
Exposure history appears controversial as a risk factor [21, 53,54]. Our research found that exposure to confirmed cases of COVID-19 was a risk factor for PTS and anxiety. This may be due to the different definitions of exposure history in various studies. The exposure history in some studies is defined as exposure to a confirmed or suspected case of COVID-19 [7,55], which somewhat increased the fear caused by uncertainty and the increase in the positive rate. At the same time, because the contact history differed from the time of the survey, as time went by, the appearance of corresponding symptoms such as fever and cough also affected the results of the study.
Our research did not find risk factors for stress, but this does not mean that the stress of HCWs during the epidemic was not great. Previous psychological surveys on the different scale about HCWs showed that the stress level of psychological impact during the epidemic was higher than that in normal times [56,57]. This shows that regardless of whether they were doctors or nurses, their age group and job title, and whether they went to work during the epidemic, HCWs were under more pressure than usual. They remained on the same frontlines to fight the new virus to the end. However, compared with that of the public in other occupations [30,58], the stress level of HCWs seems to be lower. This is likely due to the economic regression of various industries during the epidemic, which put people in other occupations at greater risk of being laid off.

Strengths and limitations
First, on March 11, the WHO announced that the COVID-19 outbreak was a pandemic. As of April 1, more than 1 million cases have been confirmed. Our research began on March 26, which was the peak of the global growth rate of COVID-19, and it was basically under control in China. This research occurred during the period when the Chinese epidemic was basically under control, and the global outbreak was officially full-blown; thus, our research has a certain degree of representativeness. Second, China is the country where the first COVID-19 case was discovered. Regarding the unknown and unpredictable nature of the new virus, the challenges faced by Chinese HCWs and the psychological impact they bore merit attention. Finally, this is a large sample multicentre study of all PICU HCWs in China. The sample basically reflects the overall psychological condition of PICU HCWs. However, the study also has certain limitations. On the one hand, it is cross-sectional, and the mental health status of the population is in a continuous process of change. Prospective studies can better determine correlation and causality. On the other hand, the survey site of this study is PICUs in mainland China. The COVID-19 epidemic is a pandemic on a global scale, and there were designated hospitals throughout China during the epidemic; therefore, this study can only represent the psychological status of Chinese PICU HCWs. Finally, because the study was completed voluntarily online, there is a certain level of bias. At the same time, deviation caused by the gender distribution of men and women in the research group cannot excluded.

Conclusions
In summary, our research shows that during the COVID-19 epidemic, 45.99%, 39.69%, 36.46% and 17.12% of PICU HCWs had varying degrees of PTS, depression, anxiety, and stress, respectively. Exposure history was an independent risk factor for PTS. Having an intermediate professional title and still working during the epidemic were independent risk factors for depression. Still working during the epidemic and COVID-19 contact history were independent risk factors for anxiety. Although the incidence of severe new coronary pneumonia in children is low, the mental health of PICU HCWs should still be considered for early intervention. At the same time, our research provides a certain basis for the occurrence of similar events in the future and early intervention for specific populations.